Diverticular Disease Flashcards
hat is a diverticulum? Where are they most commonly found?
Outpouching of the bowel wall that is composed of mucosa
Sigmoid colon
What is diverticulosis, diverticular disease, diverticulitis?
Presence of diverticulu
Symptomatic diverticulum
Inflammation of diverticulum
What is the pathophysiology fo diverticular disease?
High intraluminal pressure (due to movement of stool , perhaps lack of dietary fibre) results in protrusion or herniation of mucosa through weak areas of the gut wall adjacent to penetrating vessels. This creates pockets in which bowel contents, including bacteria can accumulate.
When inflamed, the diverticulum can perforate –> peritonitis
What are risk factors for diverticular disease?
Low dietary fibre intake Obesity in younger patients Smoking Family history NSAID use
What are the clinical features of diverticular disease?
Left lower abdominal pain (typically colicky pain relieved by defectation)
Altered bowel habit
Nausea
Flatulence
What are the clinical features of diverticulitis?
Abdominal pain with localised tenderness - classically in the left iliac fossa ( perforated diverticulum can present with signs of localised peritonism or generalised peritonitis)
PR bleeding - sudden and sometimes painless
Anorexia, nausea, vomiting
PR may demonstrated mass present secondary to abscess formation but commonly unremarkable
What investigations for diverticular disease?
?FBC, U&E< clotting, LFT, G&S/Xmatch
Blood gas for lactate for sepsis/bowel ischaemia
Urine dip for renal causes of colic
Imaging:
Flexible sigmoidoscopy for diverticular disease but not for suspected diverticulitis due tto increased risk of perforation
AXR - exclude obstruction, eCXR for perforation
CT abdo-pelvis is better when perforation or diverticulitis is suspected
How can patients with uncomplicated diverticulitis be managed
ABX, analgesia, encourage intake of clear fluids
Paracetamol as first line analgesia as opioids may cause constipation and worsen the course of disease
When should patients with diverticular disease be admitted?
Pain is not controlled with simple analgesia
Concerns of dehydration
Significant co-morbidities or immunocompromised
Significant PR bleed
Suspicion of peritonitis
Symptoms > 48 hours at home with conservative management
What is conservative management for diverticulitis
Broad spectrum IV abx
IV fluids (+ blood products if haemorrhage)
NBM - Bowel reest - only clear fluids orally
Analgesia
When is emergency surgery indicated in diverticulitis?
Perforation with faecal peritonitis
Sepsis, not responding to ABX
Failure to improve with conservative management
What is emergency surgery in diverticulitis?
Bowel resection (either with primary anastomosis - proximal part is connected to distal part of colon - or as Hartmann’s procedure - affected area of colon is resected with the formation of an end colostomy and closure of the rectal stump - reversal is possible)
Or
Laparoscopic peritoneal lavage (washout of abscess)
What is a Hartmann’s procedure?
affected area of colon is resected with the formation of an end colostomy and closure of the rectal stump - reversal is possible
What are indications for elective surgery?
Chronic symptoms, stenosis, fistulae, recurrent bleeding, significant comorbidity, immunosuppression
What are complications of diverticular disease?
Perforation - ileus and perintoitis ± shock –> bowel resection
Bower obstruction - stenting or bowel resection
Haemorrhage - sudden and painless - embolisation or colonic resection only if ongoing massive bleeding and colonoscopic haemostats unsuccessful
Fistulae - enterocoelic, colovesical (pneumoniaturia, faecaluria, recurrent UTI) colovaginal (vaginal discharge or recurrent vaginal infection) – > colonic resection
Abscesses - fever, leucocytosis, localising signs (mass) - pus may be under diaphragm –> abx, bowel rest, CT guided drainage or laparascopiuc washout
Stricutre formation in sigmoid colon
